1Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin, New Zealand

2Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT

Correspondence to: R Gauld robin.gauld{at}otago.ac.nz

Accepted 30 October 2006

Attempts to make New Zealand's health care more equitable have resulted in rapid change. But the reforms are largely untested and their effects difficult to predict

Evidence is growing that primary care has a crucial role in healthcare systems.1 Governments therefore need to ensure that they get any reforms right. In the United Kingdom, attempts to improve primary care through competition between existing general practices and new corporate entrants have been suggested to undermine some of its strengths: quality, efficiency, and equity.2 The New Zealand government has also pursued a bold strategy for improving primary care. Irrespective of its merits in principle, the strategy has produced a wide variety of organisations of varying capability and complex funding arrangements. We assess the changes and their likely effects.

Rise of organised primary care in New Zealand

Before the 1990s, organisation of primary care in New Zealand was minimal. General practitioners were mostly sole private operators and received state subsidies and patient fees for each consultation.3 Contract funding arrangements, introduced in 1993 as part of the government's market reforms of the public health system, stimulated organisation.4 In response, general practitioners formed independent practitioner associations to negotiate on their behalf with government purchasers, and various non-profit groups also developed, focusing on specific, often deprived, populations.5

By the late 1990s, primary care had progressed enormously. About 84% of general practitioners were affiliated with independent practitioner associations or other groups. Larger associations had over 100 members and well established clinical governance practices.6 An array of clinical and organisational innovations had been introduced, and information technology was widely deployed.57 Immunisation rates and other preventive measures were improving.8 New free services were being developed, financed by savings from the improved use of prescribing and laboratory budgets,9 and professional education, including dissemination of guidelines and quality improvement …